Demystifying Prior Authorization


Demystifying Prior Authorization

Have you ever been prescribed medication and went to the pharmacy only to be told “this isn’t covered” or “this needs prior authorization?”

One Friday afternoon, I was seeing a child with worsening asthma symptoms, and the family and I were making a plan on how we were going to manage this – especially as we’re going into allergy season! The asthma guidelines gave us a few different options for the next steps and there wasn’t a clear “right answer”. We discussed the different options and decided together on a new medication – one that I thought was medically sound and the family felt would fit well within her daily routine. I gave them detailed instructions on how to use the inhaler, wished them a nice weekend and walked out of the exam room feeling like we had a good plan in place. Later that afternoon the dreaded fax arrived: “this medication is not covered and requires prior authorization”

What is the prior authorization?

First, we need to delve a little deeper into some of the terms of insurance lingo. Insurance plans have a list of drugs that they cover called a drug “formulary.” Within this formulary there may be tiers of drugs, with generic or low cost drugs at the lowest tier and newer or, more expensive drugs at the highest tier. Sometimes increasing tiers have increasing copays. Other times the more expensive drugs require a prior authorization, or require you to try less expensive options first. Because the formulary is different for every insurance plan, I as a doctor usually have no idea during the visit which drugs are on formulary, which drugs require authorization, and which drugs are excluded from coverage altogether. In this case, there are seven different drugs in the class of inhaled steroids for asthma, and six of these required prior authorization by this family’s insurance plan.

So what happens next?

Ideally the pharmacy would contact us – usually by fax – and we would contact the insurance plan, and decide if the covered drug is medically appropriate, and if not initiate the prior authorization process, usually by filling out a form or calling the insurance company. The insurance company will review our argument and make a determination of whether they will cover the requested medication. This can take several business days – not ideal if it’s a time sensitive medication. In this case, we switched to the covered medication, but it used a slightly different device than we had demonstrated at the visit.

So what can patients and families do to help better advocate for themselves?

First, if you get to the pharmacy and are told there is a problem filling the medication, there are a few questions to ask:

  • Did you get the prescription sent by my doctor this afternoon?
  • Do you have the medication in stock, and if not can you order it? (Sometimes it’s a drug supply chain issue, not a prior authorization issue. Sometimes it’s both, and even when we get the authorization, the drug isn’t anywhere to be found)
  • If it needs prior authorization, how did you notify the doctor? Can I have a copy of the fax you sent?
  • Did the rejection notice provide any covered alternatives? Did it mention if the drug was “excluded from coverage.”

Second, be proactive! Let your doctor’s office know what you learned at the pharmacy and that you need a prior authorization on the medication. Hopefully we can let you know we got the fax from the pharmacy and are working on it, but if we haven’t we can use the info you gained to get the ball rolling.

Third, familiarize yourself with your insurance formulary’s list. These can usually be found on your insurance plan’s member website. These formularies are updated annually, some even quarterly. If you’re managing a chronic condition, knowing which meds are covered, which are not, and which require a trial of a different medication first – and sharing these with your doctor can help you anticipate next steps in your own or your child’s care.

Should it be this hard? Absolutely not – but it often is. I hope this helps to demystify what some of the terminology means and help you to better advocate for your family’s health!

Dr. Elizabeth Cilenti

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